The Hospital to Home Study: A Pragmatic Trial to Optimize Transitions and Address Disparities in Asthma Care

尽管有基于证据的NIH哮喘指南，儿童的总体发病率并没有显著增加。 降低在美国，哮喘占> 150，000次住院，> 600，000次急诊， 每年有近1400万人缺课。惊人的社会经济和种族不平等持续存在， 资源不足的儿童在哮喘发病率中所占比例过高。我们的长期目标是 改善所有儿童的健康结果并减少哮喘发病率的差异。我们的团队将致力于 所有哮喘住院儿童结局实现大规模改善的关键障碍 美国在任何情况下该提案的总体目标是通过开展一项 以患者为中心的多成分干预，重点关注资源不足的哮喘儿童， 儿童医院（ChH）和社区医院（CH）。干预组件是导航支持、药物 在出院时，初级保健提供者沟通，学校为基础的治疗，和家庭评估。 利用利益相关者的反馈，并在远程医疗基础设施的基础上，我们将利用务实的 有效性实施试验设计，以检验总体假设，即医院到医院的改进版本， 家庭（H2H）干预将在12个月的随访期内减少哮喘再入院。的假设 将在以下目标中进行测试。(1)：让主要利益攸关方参与，以确定实现以下目标的障碍和促进因素： 在儿童医院和社区医院实施保健到健康的组成部分。我们会进行 定性访谈，以确定障碍和促进因素，并完善每个组成部分，以实现最佳实施。 (2)：评估H2H干预与常规护理对照组儿童的健康结果 在ChH和CH研究中心因哮喘急性发作住院。我们建议进行一项多中心随机试验 在住院期间招募了340名双胞胎儿童（4 - 12岁）进行多组分干预。(3): 评价保健干预措施每个组成部分的执行情况，并评估执行工作对 健康成果。我们将使用混合方法评估可行性、可接受性和保真度， 各地点每个组成部分的执行情况及其对健康结果的影响存在差异。通过专注 关于在社区卫生服务和社区卫生服务中更广泛的实施，这一创新建议对以下方面具有重要意义： 改善哮喘管理，减少资源不足的学龄儿童的健康差距 孩子这项提案与NIH的使命一致，以解决健康差距，并将提供关键的 在所有类型的儿童护理医院实施干预措施的见解。因为 哮喘儿童的住院治疗服务于高风险人群， 确定最有效的临床方法，以提供预防性卫生服务，是迫切需要的， needed.这项工作有可能改变目前的住院临床实践范式，从只有急性 从哮喘急性发作到更广泛的公共卫生预防管理。

Despite evidence-based NIH guidelines for asthma, overall morbidity among children has not significantly decreased. In the US, asthma accounts for >150,000 hospitalizations, >600,000 emergency department visits, and nearly 14 million missed school days annually. Striking socioeconomic and racial inequities persist with under-resourced children incurring a disproportionate share of asthma morbidity. Our long-term goal is to improve health outcomes and reduce disparities in asthma morbidity for all children. Our team will address critical barriers to achieving broad-scale improvements in outcomes for all children hospitalized with asthma in the US, in any setting. This proposal’s overall objective is to improve asthma outcomes by conducting a patient-centered, multicomponent intervention focusing on under-resourced children with asthma at both children’s (ChH) and community hospitals (CH). Intervention components are navigation support, medications in-hand at discharge, primary care provider communication, school-based therapy, and home assessment. Leveraging feedback from stakeholders and building on the telehealth infrastructure, we will utilize a pragmatic effectiveness-implementation trial design to test the overall hypothesis that a refined version of the Hospital-to- Home (H2H) intervention will reduce asthma readmissions over a 12-month follow-up period. The hypothesis will be tested in the following aims. (1): Engage key stakeholders to identify barriers and facilitators for implementation of the components of H2H at children’s (ChH) and community hospitals (CHs). We will conduct qualitative interviews to identify barriers and facilitators and refine each component for optimal implementation. (2): Evaluate health outcomes of the H2H intervention compared to usual care control group for children hospitalized with an asthma exacerbation at ChH and CH sites. We propose a multi-center, randomized trial enrolling 340 caregiver-child (aged 4-12yrs) dyads during hospitalization to a multi-component intervention. (3): Evaluate implementation of each component of the H2H intervention and assess impact of implementation on health outcomes. We will evaluate feasibility, acceptability, and fidelity using mixed-methods to assess variation in implementation of each component across sites and their impact on health outcomes. By focusing on broader implementation at both ChHs and CHs, this innovative proposal has significant implications for improving asthma management and reducing health disparities incurred by under-resourced school-aged children. This proposal is aligned with NIH’s mission to address health disparities and will provide crucial insights in intervention implementation at all types of hospital settings that care for children. Because the hospitalization for children with asthma serves a high-risk population who may otherwise be difficult to reach, identifying the most clinically effective method by which to deliver a preventative health service is urgently needed. This work has the potential to shift current hospitalization clinical practice paradigms from only acute encounters for asthma exacerbations to the broader management of public health prevention.